As interventional radiologists take an increasingly patient-focused, clinical approach to their practices, there’s one demographic that IRs may be particularly positioned to treat: the LGBTQ community.
An underserved community
LGBTQ patients face their own barriers and social determinants of health, especially transgender and nonbinary individuals seeking gender-affirming care. Discrimination and misunderstanding by the healthcare system are rampant in this community, and up to 23% of transgender people report having been refused basic medical care based on their gender identity.1 In the United States, the estimated prevalence of transgender individuals has doubled since 2011 to 1.4 million individuals—which indicates that a huge number of patients are losing access to care.1
“As a member of the LGBTQ community, I have personally experienced discrimination in medical settings, as have my friends,” said Brittany Brookner, a recent Georgetown Medical School graduate. “There's an upsettingly common belief in the queer community that people won't live past 40 or even 30.”
Dr. Brookner, who will be completing her integrated-IR residency at the University of Pennsylvania, presented at SIR 2024 on the role that IR can play in the treatment of LGBTQ patients, inspired by her own experiences as both a queer patient and a physician-in-training.
“It felt like something I have the obligation and excitement to do something about, and for me, IR is the perfect field to enact change,” Dr. Brookner said.
Patients who do undergo gender-affirming treatment, both surgical and hormonal, are at risk of complications—the treatment of which can easily fall in the IR wheelhouse. As a result, IRs not only have an opportunity to build trust with an underserved community but are well-positioned to create relationships and referral patterns with colleagues who provide direct gender-affirming care.
Post-surgical care
“A lot of gender-affirming care is surgical,” Dr. Brookner said. “We already work closely with our surgical colleagues; therefore it makes sense to build bridges with those who are providing gender-affirming care to help reduce the complications of these surgeries or make recovery easier.”
For example, top surgery—a masculinizing surgery that removes, reduces or reshapes breast tissue—has multiple known complications.
“One complication is post-top surgery pain syndrome,” Dr. Brookner said. “It causes debilitating pain after masculinizing top surgery, and it’s not something that is frequently treated, or even widely talked about.”
However, the effects of post-top surgery pain syndrome are identical to postmastectomy pain syndrome, a common postoperative complication that can affect 20–68% of women who undergo mastectomies.2
“This is a known condition, one that IRs can treat through nerve blocks or radiofrequency neurolysis,” Dr. Brookner said. “The only difference between these two pain syndromes is that one is for cisgender females having mastectomies due to breast cancer, and one is for transgender/nonbinary patients undergoing gender-affirming care.”
It’s an interesting example of how nomenclature and identity can cause a patient to become almost invisible, Dr. Brookner said. However, IRs can help—even a brief procedure can help reduce pain and increase patient satisfaction after surgery, Dr. Brookner said.
Navigating clot risks
Many patients receiving gender-affirming care also turn to nonsurgical hormone replacement therapy (HRT). Though data linking testosterone use to thrombosis is limited, estrogen hormone therapy has well-documented risks of venous thrombosis as well as pulmonary embolism, cerebral venous thrombosis, retinal vein occlusion, and even myocardial infarction and stroke.3
There is evidence that the use of testosterone causes erythrocytosis. One paper discusses the interaction between testosterone, erythrocytosis and arterial thrombosis as well as venous thromboembolism (VTE).4 According to Dr. Brookner, it hasn’t been proven in an RCT; however the FDA does warn users on the risk of VTE with testosterone usage.
“Many IRs dedicate either their full practice or a sizeable amount of their practice to venous work,” Dr. Brookner said. “Their skill and knowledge in this area means they have the opportunity to educate transgender patients undergoing HRT by reaching out, letting them know the risks, and sharing that IRs are a group of physicians who can treat any potential complications in a way that will be more minimally invasive and hopefully reduce hospital stay.”
It's also a referral opportunity, Dr. Brookner said, suggesting that IRs should connect with primary care providers and those administering HRT, so that if patients come in with leg pain or other warning signs, the practitioners will know to send their patients directly to an IR.
“With that connection, the local IR will already have established themselves as a culturally and clinically competent physician who knows how to treat transgender and nonbinary patients,” Dr. Brookner said.
Culturally competent physicians
Regardless of whether an IR is seeing a patient for post-gender-affirming treatment risks, or overseeing care for unrelated disease states, all IRs can positively impact not only LGBTQ patient care but also patient experience.
“There are a lot of considerations that anyone who works in healthcare should be aware of, even just on how to use inclusive language,” Dr. Brookner said.
For example, if an IR is treating a patient for prostate artery embolization, they know the patient will have a prostate and presumably gonads. The assumption is that the patient is male—but Dr. Brookner points out that is not always the case.
“These scenarios provide the opportunity to ask for someone's gender or pronouns and not just assume based on the condition we're treating or the internal or external genitalia that someone has,” Dr. Brookner said.
A 2019 article from the Journal of Vascular and Interventional Radiology provides a sample script for such interactions, using the example of a transgender patient undergoing uterine fibroid embolization:
“Alex, we were requested to perform a uterine fibroid embolization, a procedure to treat the fibroids that may be causing you discomfort. A person with a uterus may experience symptoms of lower abdominal pain and unwelcome bleeding. How would you prefer we refer to these parts?”
This will help the patient understand the necessity of questions, ensure the patient is prepared to answer the questions, and give the patient an opportunity to provide feedback.”5
Dr. Brookner pointed out that these dialogues are crucial because of the large amount of distrust that many LGBTQ patients have toward the healthcare system.
“Physicians need to keep in mind that they’re working at a disadvantage,” Dr. Brookner said. “You're working with a population that distrusts you, is afraid of being discriminated against, and might have already delayed seeing a doctor for months or years because of that fear. You need to approach those patient interactions with a lot of empathy, care and understanding.”
The future of IR
Dr. Brookner said her presentation at SIR 2024 sparked an interesting group discussion about the future of IR and its role in LGBTQ medicine.
“There was a lot of discussion on how we can work with our primary care physicians, pediatricians and surgeons to create a setting almost similar to a tumor board,” Dr. Brookner said. “We have women’s health clinics with IRs, gynecologists and primary care physicians. So how can we make a setting like that, but for LGBTQ medicine? How will our colleagues know IRs are able and willing to treat LGBTQ patients unless we tell them and make the effort to build these relationships?”
It’s a process that would require immense cross-specialty collaboration—but one that could be fruitful for both practices and patient lives.
“I truly believe that IR has the skill, innovation and excitement necessary to treat this population,” Dr. Brookner said. “We can help our patients, both by treating their pain and managing their disease, but also by helping them get closer to living life in the bodies they deserve to be living in—and I think that’s a very exciting and powerful use of IR tools and knowledge.”
References:
- Winter S, Diamond M, Green J, et al. Transgender people: Health at the margins of society. Lancet. 2016; 388:390–400.
- Salati SA, Alsulaim L, Alharbi MH, Alharbi NH, Alsenaid TM, Alaodah SA, Alsuhaibani AS, Albaqami KA. Postmastectomy pain syndrome: A narrative review. Cureus. 2023 Oct 20;15(10):e47384. doi: 10.7759/cureus.47384. PMID: 38021812; PMCID: PMC10657609.
- Bouck EG, Grinsztejn E, Mcnamara M, Stavrou EX, Wolberg AS. Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays. Res Pract Thromb Haemost. 2023 Sep 2;7(6):102197. doi: 10.1016/j.rpth.2023.102197. PMID: 37822706; PMCID: PMC10562871.
- Cervi A, Balitsky AK. Testosterone use causing erythrocytosis. CMAJ. 2017;189(41):E1286–E1288. doi:10.1503/cmaj.170683.
- Kirkpatrick D, Stowell J, Gramstad F, Brow E, Fishback S, Lemons S. Creating a transgender-inclusive interventional radiology department. JVIR. 2019;30(6):928–931. doi: doi.org/10.1016/j.jvir.2018.12.033.
